Life-saving Therapy for Complete Traumatic Hemipelvectomy: A Case Report
Traumatic hemipelvectomy (THP) is an extremely rare and catastrophic injury, first described by Turnbull in 1978. It involves an unstable ligamentous or osseous hemipelvic injury with rupture of the pelvic neurovascular bundle, either with open or closed integuments. This injury is typically caused by high-energy trauma, such as traffic accidents, motorcycle crashes, or machinery-related incidents, and is often accompanied by pelvic fractures. The mortality rate associated with open pelvic fractures is approximately 40%, but in cases of THP, the mortality rate can reach as high as 100%. Despite its severity, there is a lack of standardized approaches for managing this fatal trauma. This case report presents a successful life-saving therapy for a patient with complete THP, emphasizing the importance of a rapid and multidisciplinary therapeutic strategy.
The patient, a 55-year-old man, was involved in a work-related accident where he was pulled into a cement mixer, resulting in the complete tearing off of his right lower limb. Upon initial examination, the patient was conscious but drowsy, with a patent airway, an injury severity score of 75, blood pressure ranging from 70 to 85/40 to 50 mmHg, and a pulse of 120 beats per minute. At the accident scene, paramedics applied bandaging with strong mechanical pressure to control hemorrhage, and intravenous rehydration and oxygen inhalation were immediately initiated.
The patient was admitted to the hospital approximately one hour after the injury. Physical examinations revealed an open wound extending from the right costal arch to the right pubic tubercle, traversing through the perineum and ending near the right sacroiliac joint. The entire area was stripped of skin, with the peritoneum being the only structure holding the abdominal contents in place. The wound was contaminated with cement and other foreign materials. The displaced extremity was cold, extensively crushed, and pulseless.
Upon arrival in the emergency department, the patient received immediate fluid resuscitation through one central venous and two peripheral lines. Tetanus prophylaxis and broad-spectrum antibiotics were administered. Computed tomography (CT) images confirmed the loss of the right lower limb and the right lower abdominal wall, including the right ilium, pubis, and ischium. There was no intra-abdominal injury, and the bladder and rectum were intact. CT angiography revealed transection of the right common iliac vessels.
A multidisciplinary team, including an orthopedist, a urologist, and a general surgeon, developed a therapeutic strategy. The patient was placed on the operating table and given general anesthesia. Systemic exploration of the pelvic wound revealed extensive skin loss from the right lower abdomen, with the severely contaminated peritoneum being the only structure covering the right side of the abdomen. Bowel peristalsis was observed, and the right side of the scrotum was avulsed, with the exposed testis and spermatic cord extravasating through the wound. Some soft tissue surrounding the anus and right ilium was missing, leaving the sacrum exposed. Arterial bleeding was observed in the pelvic cavity, and the right external and internal iliac vessels were transected and thrombosed. The main vessels were ligated and sutured to stop the pelvic hemorrhage. The wound was repeatedly washed with saline, hydrogen peroxide, and iodophor diluent. Due to extensive skin loss, the wound was left open but covered with a vacuum-sealing drainage (VSD) device for temporary wound management. A rectal tube was used to preserve bowel integrity.
During surgery, the patient received 800 mL of packed red blood cells, 1000 mL of crystalloids, and 1500 mL of colloids, totaling 3300 mL of fluids. Post-operation, the patient was transferred to the intensive care unit (ICU) with mechanical ventilation support. He received a blood transfusion of 600 mL, aggressive fluid resuscitation, and preventive treatment with broad-spectrum antibiotics (imipenem 0.5 g every 6 hours, metronidazole 1 g every 8 hours) and antifungal medication (linezolid 0.6 g every 12 hours) for 12 days.
Despite empirical antibiotic treatment, the patient’s fever persisted throughout his ICU stay. The white blood cell count peaked at 16.95 x 10^9/L on day 5 in the ICU. Closed drainage was performed after X-rays revealed pneumothorax in the right lung and pneumonia in the left lung. CT scans showed no localized pelvic abscess. On day 6, the patient underwent a second operation for debridement. Granulation tissue was observed on the wound surface, and devitalized tissue was removed. Pus samples were collected for culture. Repetitive irrigation and debridement were performed weekly for two months, and VSD therapy was continued. Analysis of the pus sample revealed the presence of Proteus mirabilis and Providencia alcalifaciens. A blood sample obtained on day 9 showed evidence of Pseudomonas aeruginosa. The antibiotic regimen was changed to a combination of meropenem (1 g every 8 hours), levofloxacin (0.5 g daily), tigecycline (0.1 g every 12 hours), and fluconazole (0.4 g daily) for two weeks. To prevent fecal contamination of the pelvic wound and preserve digestive system function, a diverting colostomy was performed on day 14. The patient’s body temperature remained high, fluctuating slightly until day 20 in the ICU, then steadily dropped to baseline values by day 25.
On day 21 post-admission, the skin defect was well-defined, measuring 28 x 21 cm². During his seven-week stay in the ICU, the patient received extensive psychiatric, nutritional, and chronic pain management. Two months after the complete THP, the patient’s skin regenerated, and the skin defect decreased by 50% in size. VSD therapy was discontinued, and the well-defined skin defect was closed with a split-skin graft from the patient’s left thigh.
At 10 weeks post-injury, the patient was able to walk with crutches and successfully performed squatting maneuvers. The patient remained hospitalized for a total of 72 days and received a semi-laparotomy prosthesis for physical rehabilitation five months post-operatively. At the last follow-up examination, 12 months after the injury, the wound had healed uneventfully. The patient retired due to disability but was able to take care of himself in daily life. He occasionally experienced phantom pain, which was bearable, and did not require narcotic or non-opioid pain medication. No symptoms of depression were reported.
THP is a high-energy injury that often results in damage to multiple bodily systems. The massive blood loss and hypovolemic shock associated with THP are the most common causes of death. Initial management at the accident scene should focus on controlling hemorrhage through nasal packing, surgical ligation, or embolization. Blood transfusion and aggressive fluid replacement are essential to stabilize blood pressure.
In cases of complete THP, the decision to retain the limb is controversial. Attempting to reimplant the limb can lead to complications such as life-threatening hemorrhage, reperfusion injury, organ failure, acute respiratory distress syndrome, and sepsis. However, a limb without motor function or sensation can still be useful for sexual, urinary, and anal functions and has a significant impact on the patient’s psychological well-being. There is no predictive scale or scoring system to assist in decision-making, but immediate hemipelvectomy is generally recommended as a life-saving therapy, as extremity-saving approaches increase mortality risks.
Sepsis is another common life-threatening complication during hospitalization for THP. Infection can result from severe wound contamination, soft tissue necrosis, inadequate debridement, and contamination from the urinary and intestinal systems. In this case, a proximal diverting colostomy was necessary to prevent further wound contamination and sepsis. The extensive skin loss was managed with a VSD device until skin regeneration allowed for a skin graft, which is beneficial for healing large wounds and managing infection. During the ICU stay, the patient developed pneumothorax and pneumonia, leading to persistent fever. A combination of meropenem, levofloxacin, tigecycline, and fluconazole was administered to prevent bacterial infection.
This case highlights the importance of emergency admission and a multidisciplinary team approach in the survival and recovery of a patient with complete THP. The successful outcome was achieved through rapid and coordinated efforts involving orthopedists, urologists, general surgeons, and intensive care specialists. The patient’s recovery was marked by extensive psychiatric, nutritional, and chronic pain management, demonstrating the comprehensive care required for such severe injuries.
doi.org/10.1097/CM9.0000000000001372
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